Youth Sports Medical Information And Release Form
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1YOUTH SPORTS MEDICAL INFORMATION
AND RELEASE FORM
Player’s Name _________________________________________
D.O.B__________________
Father’s Name____________________________________ Home Phone______________________
Work Phone______________ Cell Phone ______________ Email____________________________
Mother’s Name___________________________________ Home Phone______________________
Work Phone______________ Cell Phone ______________Email____________________________
Emergency Contact________________________________ Phone ___________________________
MEDICAL INFORMATION:
Family Physician’s Name________________________________________________________
Phone_________________________ Address________________________________________
Allergies and/or Medical Conditions (list): ________________________________________________
Medications (list): _____________________________________________________________________
Date of Last Tetanus booster ________________________________________
Person Responsible for Charges (if different then from above)________________________________
Insurance Company__________________________________ policy # _________________________
I/we hereby grant consent to any and all health care providers to administer any
necessary medical care as a result of injury/illness. This consent includes First Aid
and transportation to/from health care providers.
Parent Signature____________________________________ Date_______________
Parent Signature______________________________________ Date_____________
NOTE: This release is to be carried by head/assistant coach to all practices and games.
WARNING: Protective equipment cannot prevent all injuries a player might receive while participating in
athletic activities.
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